COVID-19 Scan for May 20, 2021

News brief

1 in 7 adult COVID-19 patients requires care for new illness after infection

One in seven US adult COVID-19 patients developed at least one new illness requiring medical care after recovery from their infection in 2020, finds an observational study yesterday in BMJ.

The so-called COVID-19 "long-haulers" developed complications involving a range of organs and systems at least 3 weeks after infection. The complications affected the heart, kidneys, lungs, and liver, along with mental illnesses.

Researchers from OptumLabs at UnitedHealth Group in Minneapolis led the study, which consisted of mining health insurance records from Jan 1 to Oct 31, 2020, to identify 266,586 COVID-19 patients 18 to 65 years diagnosed as having at least 1 of 50 medical conditions as many as 6 months after infection. The patients were matched to two comparison cohorts without COVID-19 infection in 2019 or 2020 and one group diagnosed as having other viral lower respiratory tract infections.

Fourteen percent of adults infected with COVID-19 went on to require medical care for at least one new condition—5.0% more than in the 2020 comparison group and 1.7% more than in those who had a different viral respiratory infection. Also, the risk of specific conditions, including chronic respiratory failure, heart rhythm abnormalities, diabetes, fatigue, amnesia, and anxiety, was higher in the long-hauler group than in all comparison cohorts.

The absolute risk was low, at an excess 0.02 to 2.26 per 100 people in the 2020 comparison cohort. Patients at highest risk were 50 years and older and those with preexisting underlying illnesses or who were hospitalized for their infections.

In a BMJ press release, the authors said that the study suggests that as more people are infected with COVID-19, "the number of survivors with potential sequelae after COVID will continue to grow."

In a linked editorial, Elaine Maxwell, PhD, of the National Institute for Health Research in London, said that while it's unclear how long COVID-19 complications will continue after infection, they impose a burden on those affected, who may struggle to work or care for dependents. "Long COVID is also putting a strain on healthcare services, which have been already decimated by the pandemic," she said. "Identifying risk factors would facilitate triage and faster access to specialist care."
May 19 BMJ study, press release, and editorial

GAO: Almost all US nursing homes had multiple COVID-19 outbreaks

From May 2020 to January 2021, US nursing homes had an average of three COVID-19 outbreaks, according to a Government Accountability Office (GAO) report released yesterday.

The authors used Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) data and representative and expert interviews to look at COVID-19 outbreaks in 13,380 nursing homes (88% of all CMS-certified nursing homes). An outbreak was defined as anytime a staff member or resident was diagnosed with COVID-19, and it did not end until at least 2 weeks after the last identified case.

The average nursing home had three outbreaks, and 93.8% had more than one. Less than half a percent had no outbreaks. Data also showed that 2.0% of outbreaks were able to be contained after the initial week and that most (84.5%) lasted at least 5 weeks. The average number of COVID-19 cases for these longer outbreaks was 56, and for those shorter, the average case number was 13. Overall, 65.2% of nursing homes reported that the outbreak was first identified with a staff member who tested positive.

The authors found that most of the longer outbreaks were between October and December 2020 and were more likely to occur in nursing homes with a larger number of beds. For instance, those with less than 50 beds were 12% of the analyzed nursing homes but made up only 9% of longer outbreaks and 28% of shorter outbreaks. More than 75% of nursing homes in each state experienced long-term outbreaks except for those in Alaska, Hawaii, Maine, Massachusetts, New Hampshire, Oregon, Vermont, and Washington.

"Officials frequently highlighted the risks posed by a failure or inability of a nursing home to implement robust infection control practices to control the spread of the virus," the authors write, citing the inability to quickly test or quarantine and staffing shortages. "Future GAO reports will examine more broadly infection prevention and control and emergency preparedness in nursing homes and CMS's response to the COVID-19 pandemic."
May 19 GAO report

Low vitamin D not associated with COVID-19 infection

Low levels of vitamin D were not associated with SARS-CoV-2 positivity after data were adjusted for variables such as comorbidities, race, and sex, according to a JAMA Network Open study yesterday.

The researchers looked at data from 18,148 Quest Diagnostics employees and spouses across the country who participated in both a health screening from September 2019 to January 2020 (pre-pandemic) and August and November 2020. The mean age of participants was 47 years, and 67.1% were women. Nine hundred (5.0%) tested seropositive, or having SARS-CoV-2 antibodies. The researchers note that similar to other studies, racial disparities appeared: 1 in 3 seropositive people were Black, compared with 1 in 6 seronegative people.

Before adjusting for sex, age, race, US geographical region, body mass index, blood pressure, smoking status, and education, lower vitamin D levels did appear to have an association with seropositivity (odds ratios [ORs], 1.28 to 1.70). After adjustment, however, there was no significant association, with adjusted odd ratios for those with low vitamin D falling between 0.93 to 1.09. During the course of their study, the researchers assessed vitamin D levels before and after the pandemic started, deficient versus insufficient levels (20 vs 30 ng/mL or less), and even a simulation that accounted for 10% of infected people not testing seropositive.

Minority status, not having a college education, and obesity were positively associated with seropositivity, and high blood pressure, smoking, and residency in the northeastern and western parts of the country were negatively associated.

"Although SARS-CoV-2–seropositive individuals did have lower vitamin D levels than seronegative individuals, low vitamin D levels were not independently associated with the risk of seropositivity," the researchers conclude.

"Well-done observational studies are among the means by which we can determine which therapies are worth bringing to clinical trials," Michael A. Polis, MD, MPH, writes in an invited commentary, noting that past vitamin D studies often did not take into account confounding variables. "It is incumbent on us all to recognize when and what analyses are needed before funding and initiating large clinical trials on speculative or insufficient information." Polis is an infectious disease consultant in Bethesda, Maryland.
May 19 JAMA Netw Open study and commentary

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News Scan for May 20, 2021

News brief

Pneumococcal vaccines may affect use of kids' antibiotics

Antibiotic prescribing for young children in Israel sharply declined following implementation of pneumococcal conjugate vaccine (PCV), Israeli researchers reported today in Clinical Infectious Diseases.

Using data from the country's largest health maintenance organization, the researchers conducted an interrupted time series analysis of dispensed antibiotic prescription (DAP) rates for Israeli children under the age of 5 from July 2005 through June 2018. The 7-valent vaccine (PCV7) was introduced into Israel's National Immunization Plan (NIP) in 2009, and the 13-valent vaccine (PCV13) has gradually replaced it since 2010. Since then, a marked reduction in respiratory tract infections (RTIs) in Israeli children has been observed, but the impact on antibiotic prescribing has not been investigated.

The study also included a comparison of the DAP rate between Jewish and Bedouin populations in southern Israel, as prior to PCV implementation, pneumococcal diseases and RTIs were more prevalent among Bedouin children. PCV uptake was similar in Jewish and Bedouin children.

Following the implementation of PCV7/PCV13, DAP rates for children under 5 abruptly and significantly declined, largely driven by a decrease in amoxicillin and amoxicillin-clavulanate prescriptions, which prior to PCV implementation accounted for 75% of pediatric DAPs. The decline continued and stabilized at a reduced level within 5 years. Children younger than 2 and Bedouin ethnicity were significantly associated with higher pre-PCV DAP rates, but also with a faster and greater decline post-PCV, achieving near elimination of gaps between ages and ethnic groups.

Among all children under 5, the annual mean reduction (per 1,000 child-years) of DAPs ranged between an absolute incidence rate ratio of 344.7 and a relative incidence rate ratio of 110.4. For amoxicillin/amoxicillin-clavulanate, the respective reductions were 300.2 and 142.3. Azithromycin was the only drug with increasing trends following PCV implementation.

"The overall DAP reduction rate translates into reduced pressure on the entire body microbiota," the study authors wrote. "However, consumption still remains high. Therefore, although PCV implementation is an important tool against antimicrobial resistance, efforts to develop other tools such as improvement of stewardship programs must be continued."
May 20 Clin Infect Dis abstract

New expert panel to advise global health leaders on zoonotic disease

Four international organizations today announced the formation of a new expert panel to improve understanding, and stop the emergence and spread, of zoonotic diseases.

Operating under the One Health approach, which recognizes the links between the health of people, animals, and the environment, the One Health High-Level Expert Panel will advise the United Nations Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health, the United Nations Environment Programme, and the World Health Organization (WHO) on the development of a long-term action plan to avert outbreaks of infectious diseases that emerge in animals.

According to a WHO press release, the ultimate aim of the panel will be to develop evidence-based recommendations for global, regional, national, and local action to help prevent zoonotic disease outbreaks that could trigger pandemics. Among the first steps will be conducting systematic analyses of research around factors that lead to disease transmission between animals and humans, developing risk assessment and surveillance frameworks, and identifying good practices for preventing zoonotic disease outbreaks.

The panel plans to focus on a few critical areas that could contribute to the emergence of diseases similar to H5N1 avian flu, Middle East respiratory syndrome (MERS), Ebola, and Zika, including food production and distribution, urbanization and infrastructure development, international travel and trade, and activities that affect biodiversity loss and climate change.

"This panel will contribute to advancing the One Health agenda, by helping to better understand the root causes of disease emergence and spread, and informing decision-makers to prevent long-term public health risks," FAO Director General Qu Dongyu said at press conference announcing the panel. "I encourage it to be a shining example of silo-breaking, systems thinking and open dialogue."
May 20 WHO press release

CWD detection in Virginia deer prompts new management zone

Wildlife officials in Virginia last week announced that routine surveillance turned up chronic wasting disease (CWD) in a 2-year-old deer that a hunter shot in Montgomery County and took to a taxidermist. The finding is significant, given that the harvest location is 160 miles from the closest earlier detection in the state.

In a press release, the Virginia Department of Wildlife Resources (VDWR) said the deer was brought to the taxidermist in November 2020, which assisted with obtaining a sample for testing as part of regular surveillance during the hunting season. The hunter did not notice any disease signs, and the deer appeared to be in good condition. So far, there is no known link to earlier detections.

Because of the distance from earlier detections, officials conducted an extensive investigation to confirm the harvest location. Based on the Montgomery County detection, officials created a new disease management area, marking the third for the state. The new areas includes Floyd, Montgomery, and Pulaski counties, which are now under new regulatory actions related to deer, including movement of carcasses and parts containing brain or spinal cord tissue. Further regulatory changes will be proposed next week at a wildlife resources board meeting.

The VDWR said it will expand testing in the new management area and in certain surrounding counties during the 2021-22 hunting season. Officials have been monitoring CWD prevalence in Virginia deer for more than 10 years. Since 2009, 109 of Virginia's deer have tested positive for CWD. During the current season, the Montgomery County sample was the only one of about 2,600 taxidermist-submitted samples that tested positive for CWD.

CWD, a fatal prion disease that affects deer, elk, reindeer, and moose, has been confirmed in 26 US states and three Canadian provinces but has not been reported in people.
May 12 VDWR statement

CDC ends probe of multistate ground turkey-linked Salmonella outbreak

The US Centers for Disease Control and Prevention (CDC) has wrapped up its investigation of a Salmonella Hadar outbreak tied to ground turkey, which sickened at least 33 people in 14 states.

The final outbreak notice, posted on May 18, reflects five more cases and two more affected states since the CDC's last update on Apr 12. The most recent illness-onset date was Apr 22. Based on information from 22 cases, 4 people were hospitalized, and no deaths were reported.

Sampling during an investigation by the US Department of Agriculture (USDA) Food Safety and Inspection Service (FSIS) yielded the outbreak strain in an unopened package of ground turkey from a sick person's freezer. The outbreak strain was also identified in routine turkey samples collected by FSIS and state officials from multiple companies. On Apr 10, the USDA issued a public health notice for about 211,000 pounds of ground turkey products produced by Plainville Brands, of New Oxford, Pennsylvania, which were produced in December and distributed nationally. The trace-back investigation had linked the brand to the sample from the patient's freezer that tested positive.

Whole-genome sequencing revealed that the strain that sickened the patients was resistant to two antibiotics: streptomycin and tetracycline, the CDC said. It added that most people recover without antibiotic treatment and that the resistance wouldn't likely affect treatment choice.

Ground turkey products have been linked to several Salmonella outbreaks in the past, and health officials urge consumers to take precautions when handling and cooking raw turkey.
May 18 CDC outbreak notice
Apr 12 CIDRAP news scan